CurrentColorado Rocky Mountain Health PlansPolicy N/A

Washington Prior Authorization Request Form — Prostate Cancer Medications

A prior authorization form used by Colorado Rocky Mountain Health Plans for requests of prostate cancer medications in Washington — captures patient, prescriber, diagnosis subtype, treatment history, and required documentation to support approval. Affects prescribers, pharmacies, and reviewers processing PA for prostate cancer therapies.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyWashington Prior Authorization Request Form — Prostate Cancer Medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Washington Prior Authorization Request Form with patient, prescriber, medication, diagnosis subtype, prior treatments, and supporting documentation; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12numbered form questions or items

5diagnosis subtypes listed

24checkbox options (approx.)

24hminimum review allowance

Coverage criteria and required information

Information required to consider coverage

Coverage consideration requires completion of the form items specific to the patient's prostate cancer subtype and associated clinical questions; supporting documentation must be provided.

Form completion: Form must be fully completed with patient demographics, prescriber details, medication name/strength/directions/quantity, and prescriber signature

Allow at least 24 hours for review

Diagnosis subtype selection: One diagnosis subtype must be selected from: castration-resistant, metastatic castration-sensitive, metastatic hormone-sensitive, non-metastatic castration-resistant, non-metastatic castration-sensitive, or other

Associated follow-up questions depend on selection

Castration-resistant-specific: If castration-resistant prostate cancer selected, indicate whether the requested medication will be used as monotherapy, confirm HRR gene mutation status and whether talazoparib will be combined, and document prior abiraterone use if ineffective, not tolerated, or contraindicated

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyWashington Prior Authorization Request Form — Prostate Cancer Medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Metastatic castration-sensitive/hormone-sensitive-specific: If metastatic castration-sensitive or hormone-sensitive selected, indicate presence of risk factors (Gleason Score ≥ 7, bone lesions, or measurable visceral metastases), document prior abiraterone use if ineffective, not tolerated, or contraindicated, and for darolutamide indicate whether it will be combined with docetaxel

Non-metastatic criteria: If non-metastatic castration-resistant or castration-sensitive selected, indicate node positivity, Gleason Score ≥ 8, tumor stage T3 or T4, PSA concentration ≥ 40 ng/mL, or PSA doubling time < 6 months or PSA ≥ 20 ng/mL while on androgen deprivation therapy

Chart notes, labs and all diagnostic tests confirming diagnosis are required with this request

Complete all pages of the Washington Prior Authorization Request Form and provide every requested item on the form. The form instructs: "Please complete this entire form... This form may contain multiple pages. Please complete all pages to avoid a delay in our decision. Allow at least 24 hours for review." Failure to fully complete the form, omit required patient or prescriber details, medication information, or the signature may result in a delay or denial of the request.

The form itself does not include language declaring any items as "not medically necessary." It instead focuses on required completion and submission details and instructs providers to supply supporting documentation; absence of explicit "not medically necessary" statements on the form does not change the need to meet the form's completion and documentation requirements.

Clinical thresholds and coding-related criteria

PSA thresholds and timing

PSA concentration thresholdPSA ≥ 40 ng/mL

PSA doubling timePSA doubling time < 6 months

PSA on ADT thresholdPSA ≥ 20 ng/mL while on androgen deprivation therapy (e.g., GnRH analogs)

Gleason score thresholds

Gleason score - lower thresholdGleason Score ≥ 7 (Grade Group > 2)

Gleason score - high thresholdGleason Score ≥ 8

What the provider must do when submitting a request

Prior Authorization

Prior Authorization Required

Prior authorization is required for prostate cancer medications. Complete and fax the Washington Prior Authorization Request Form to 866-940-7328. Allow at least 24 hours for review. Incomplete forms or missing information may delay or result in denial of the request.

Complete the entire Washington Prior Authorization Request Form — include patient, prescriber, medication, diagnosis subtype, prior treatment history, and signatures.
Fax completed form to 866-940-7328. For questions call 800-310-6826.
Allow at least 24 hours for review.

Step Therapy

Therapy Sequencing / Prior Treatment Questions

Therapy sequencing and prior treatment history must be documented on the form. The form captures prior abiraterone use and whether it was ineffective, not tolerated, or contraindicated, and other sequencing/intolerance questions relevant to therapy selection.

For castration-resistant disease: indicate whether abiraterone was ineffective, not tolerated, or contraindicated (form question 8).
For metastatic castration-sensitive/hormone-sensitive disease: indicate prior abiraterone status (form question 10) and, if requesting darolutamide, whether it will be used with docetaxel (form question 11).
For HRR-mutated disease, indicate whether HRR mutation confirmed and if combination with talazoparib is intended (form question 7).

Documentation Required

Required Supporting Documentation

Required supporting documentation must accompany the request. Chart notes, laboratory results, and diagnostic testing that confirm the diagnosis and relevant risk factors are required.

Attach chart notes and documentation confirming diagnosis and clinical status.
Include labs and diagnostic tests (e.g., PSA values, imaging reports) that support the selected diagnosis subtype and risk factors.
For non-metastatic or node-positive disease, provide documentation of Gleason score, tumor stage (T3/T4), PSA concentration and PSA doubling time as applicable.

Denial Risk

Provider Actions — Complete All Pages and Provide Documentation

Failure to complete all pages of the Washington Prior Authorization Request Form or to provide the required documentation may delay review or result in denial of the request.

Ensure all form pages are completed, including patient demographics, prescriber information, medication name/strength/directions, and prescriber signature and specialty.
Provide documentation of disease stability or clinical response for continuation requests when applicable (form question 1).
Attach documentation of bilateral orchiectomy status and whether hormone suppression will be used (form questions 3 and 4).
Incomplete submission may be returned or denied.

Form purpose and captured clinical subtypes

The form captures multiple clinical subtypes of prostate cancer for which different follow-up questions are required. Providers must select one diagnosis subtype from: castration-resistant prostate cancer (follow-up questions 6–8), metastatic castration-sensitive prostate cancer (questions 9–11), metastatic hormone-sensitive prostate cancer (questions 9–11), non‑metastatic castration‑resistant prostate cancer (question 12), non‑metastatic castration‑sensitive prostate cancer (question 12), or other with specification. These subtype selections drive the associated clinical questions about prior therapies, combination use, and relevant risk features needed to consider coverage.

High-risk and metastatic disease features

High-risk features for non-metastatic disease

Nodal statusNode positive

Gleason scoreGleason Score ≥ 8

Tumor stageTumor stage T3 or T4

PSA concentrationPSA ≥ 40 ng/mL

PSA kinetics on ADTPSA doubling time < 6 months or PSA ≥ 20 ng/mL on androgen deprivation therapy

Risk factors for metastatic disease

Gleason scoreGleason Score ≥ 7 (Grade Group > 2)

Skeletal involvementBone lesions

Visceral metastasesPresence of measurable visceral metastases